Unlocking the potential of natriuretic peptide testing in primary care: A roadmap for early heart failure diagnosis
Authors: Antoni Bayes‐Genis, Giuseppe Rosano
Journal: European Journal of Heart Failure (2023)

A correct diagnosis is three-fourths the remedy. Mahatma Gandhi With more than 15 million cases in Europe and a mortality of around 40–50% at 5 years, heart failure (HF) is one of the leading threats to public health.1 Disability, high hospitalization rate and mortality not only impact patients and their relatives, but they also contribute to countries spending approximately 1–2% (€ 23.6 billion totally in the European Union) of their total healthcare budgets on HF associated costs.2 Consequently, HF is generating a high disease burden, which is projected to markedly escalate over the next decade due to the increased survival from acute cardiovascular events, ageing population and unhealthy lifestyles.1 Early HF diagnosis in primary care and subsequent timely treatment with disease-modifying drugs plays a critical initial role in mitigating HF complications, hospitalizations, and death.3 Rule out HF in primary care reduces referrals to specialists and the requirement for more advanced diagnostic interventions by one quarter, thereby freeing up healthcare resources and reducing costs.4 At the same time, the identification of patients with high likelihood of HF allows prompt diagnosis and treatment thereby having an impact on events. Consequently, natriuretic peptide (NP) testing in primary care has been shown to provide significant cost-benefits.5 These are critical considerations for sustaining healthcare systems in the aftermath of the COVID-19 pandemic. Still, HF is often diagnosed several years after symptom onset, during hospitalization for an acute decompensation or complication.6 Transforming healthcare systems to enable earlier HF diagnosis in primary care is possible but it requires multiple interventions including improving access to blood-based biomarker (NP) testing in primary care.7 Both the universal definition of HF and European guidelines have put NP testing in primary care at centre stage for better HF diagnosis and management.3, 8 Making NP testing more widely available in primary care is a critical step towards unlocking early diagnosis of HF and reducing its overall burden. Prioritizing early HF diagnosis as a public health mandate is imperative and essential to encourage the adoption of NP testing in primary care. One powerful approach is to create a comprehensive HF diagnosis strategy, which can be integrated into a national cardiovascular health plan, and includes specific, measurable goals. To ensure that the strategy is effective, national quality standards should be put in place, and regular audits should be conducted. These measures can help to identify regional disparities and provide insights that aid in local efforts to address inequalities in the early diagnosis of HF. An illustration of a comprehensive HF policy strategy is the powerful association of the 25in25 initiative and the quality standards from the National Institute for Health and Care Excellence (NICE). The 25in25 initiative set the objective to reduce HF mortality in the first year after diagnosis by 25% in the next 25 years.9 In the meantime, the 2023 NICE chronic HF quality standards state that 'Adults presenting in primary care with suspected HF have their N-terminal pro-B-type natriuretic peptide measured'.10 By aligning their efforts, the 25in25 initiative and NICE quality standards have helped to establish clear guidelines and best practices for healthcare providers, making it easier to achieve their shared public health objectives. To promote early HF diagnosis, it is also essential to conduct public awareness campaigns that increase understanding of the symptoms of HF. Knowledge of HF in the general population is often poor, and it is frequently less comprehended than other public health risks, such as cancer, stroke or heart attacks.11 In one large international survey, 31% of lay persons considered HF as normal symptom of old age.11 Public education on lifestyle modifications, such as maintaining a healthy diet, engaging in regular exercise, and quitting smoking, can be instrumental in the prevention of HF. Awareness campaigns are needed to educate the public about the signs and symptoms of HF and encourage them to seek medical attention early. Collaborating with patient advocacy groups to launch media campaigns, incorporating attention-grabbing slogans or acronyms like Breathlessness, Exhaustion, Ankle swelling, Time for a simple blood test (B.E.A.T.), could significantly enhance early recognition of symptom and NP testing in primary care, promoting greater awareness and engagement.12 Enhancing physicians' knowledge regarding the use of NPs can empower primary care physicians and provide them with stronger arguments to support their referrals to specialized care. Timely identification of HF is strongly associated with patients' ability to access healthcare professionals. Given the current shortage of healthcare workers and the escalating demand for medical services, this is a critical point. Conducting NP testing can help to optimize the diagnosis, referral, and overall care pathway for HF patients, thereby freeing up the time of primary care physicians and specialists.4 In addition, other measures, such as the use of digital tools for telemedicine and patient monitoring, can facilitate access to primary care.3 To ensure access to quality care for HF, it is also important to upskill the existing healthcare workforce.3 One way to achieve this is by accrediting, funding, and expanding the roles of nurse specialists and clinical pharmacists, thus supporting sustainable growth in multidisciplinary teams. Strengthening diagnostic infrastructure and expanding diagnostic capabilities in primary care is also fundamental.13 This can be achieved by providing dedicated funding and increasing physical capacity for diagnostics, including point-of-care testing.13 By doing so, clinicians can make faster and more precise diagnoses, even in rural or remote areas, thus reducing inequalities in HF diagnosis and management. A focused investment in diagnostic capacity can be achieved by implementing community diagnostic centres in primary care throughout the country, which can enhance access to early diagnostic tests.13 Such initiatives, especially if including point-of-care testing, are essential for improving HF management where the patients live, and thus minimizing the need for higher-level care facilities. The availability and use of NP testing in primary care is greatly impacted by reimbursement policies. Reimbursement policies exist for guideline-directed medical therapy for the treatment of HF with strong implications for patient outcomes.14 However, basic reimbursement and funding schemes for key diagnostics in the early diagnosis of HF in primary care are not comprehensively in place in all countries (Figure 1).14, 15 In countries and regions where NP testing is fully reimbursed, primary care physicians have easy access to this diagnostic tool.7 This can lead to earlier detection and treatment of HF, which can improve outcomes for patients and reduce healthcare costs in the long term.7 By contrast in countries where NP testing reimbursement is partial or non-existent, primary care physicians may face limited access to NP testing, which can lead to delayed detection and treatment of HF and may exacerbate healthcare disparities.14 The goal of any reimbursement policy should be to incentivize high-quality, patient-centred care that prioritizes the accurate diagnosis of HF, accelerating the most appropriate treatment.15 By designing policies that align with this goal, healthcare systems can encourage primary care physicians to invest the necessary time and resources into the HF diagnostic process, leading to improved patient outcomes.7 The availability of NPs as point-of-care testing in pharmacies is a goal worth pursuing. The notable success of pharmacies administering COVID tests across Europe serves as a compelling example, demonstrating the feasibility and widespread acceptance of such a model. Leveraging the infrastructure and convenience of pharmacies has the potential to improve access to NP testing, enabling timely detection and management of HF. The European guidelines and universal definition of HF unambiguously advocate for the use of NP testing in primary care.3, 8 The translation of these recommendations into national guidance is important to make them more accessible and easier to understand, which can help to improve adherence to standards of quality. Tailoring national guidelines to the specific healthcare systems, resources, and cultural contexts can help overcome implementation barriers and improve guideline uptake.15 National regulations and the structure of primary care may vary between countries, such as the authorization of point-of-care testing or the availability of community health centres and HF nurses.14 By leveraging the local organization of primary care, national guidelines can be better implemented, leading to improved NP testing and early HF diagnosis. Finally, combined European and national initiatives, such as the Peptide for Life initiative,16 can act as a foundation for designing local training programmes for healthcare professionals and public sector workers, and further move forward adoption of NP testing. Raising awareness among healthcare professionals is necessary but not sufficient for enhancing the adoption of NP testing in primary care; changing medical behaviour is equally crucial. Encouraging the use of clinical decision support systems can help healthcare professionals to select NP testing as the default choice and interpret the results accurately. Quality improvement initiatives should be leveraged to inform primary care physicians about the prescribing behaviour of their peers and how it compares to best practice guidelines. This could encourage physicians to align their behaviour with the social norm of prescribing NP testing for early HF diagnosis. The way information is presented can also influence how people perceive and respond to it. In this case, the benefits of prescribing NP testing could be framed in a way that emphasizes the potential positive outcomes for patients and the potential cost savings for the healthcare system. Primary care physicians could also be rewarded with continuing medical education credits or financial incentives. All these different nudges could really make a difference in terms of adoption of NP testing in primary care and early HF diagnosis. Policy makers play a significant role in promoting Awareness, Access and Adoption (3 A's strategy) (Table 1) of NP testing in primary care. By making this simple diagnostic tool readily available, there is significant potential to improve the diagnosis and management of HF, resulting in better patient outcomes and reduced healthcare costs. Initiatives aimed at expanding access to and promoting the use of NP testing in primary care should be given priority by policy makers. Conflict of interest: A.B.G. reports advisory boards and/or lectures for Abbott, AstraZeneca, Bayer, Boehringer Ingelheim, Novartis, Roche Diagnostics, Vifor. G.R. has nothing to disclose.